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People in Essex enjoy good health and wellbeing Essex County Council Commissioning Strategy Version: consultation draft

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Contents page Indicators, Principles and Leads 2 Summary Slides 5 Relationship with other Outcomes and Strategies 7 Overarching Strategic Actions 8 Quality Criteria 9 People in Essex have a healthy life expectancy 11 Reduced differential in life expectancy across different areas of Essex 13 Prevalence of Healthy Lifestyles 16 Percentage of Children Achieving at School 34 Percentage of Working Age People in Employment 37 Percentage of People living in Safe and Suitable Housing 41 Percentage of Households living in Fuel Poverty 45 Prevalence of mental health disorders amongst Children 50 Prevalence of mental health disorders amongst Adults 54 Teenage Pregnancy Rates 58 Customer/User Views 63 Our Partners and our Relationship with them 64 Category Strategy 68 Risks and Mitigations 72 Delivering Change within our financial envelope 73 Information Governance and Information Technology Strategies. 75

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2. People in Essex enjoy good health and wellbeing Group Agreed indicators (and groups) Group Lead A People in Essex have a healthy life expectancy Mike Gogarty supported by the ICDs Reduced differential in life expectancy across different areas of Essex Prevalence of healthy lifestyles Percentage of Essex residents who consider themselves to be in good health Life satisfaction rates (ONS condition of wellbeing) B Percentage of children achieving at school Tim Coulson Paul Bird Percentage of working age people in employment C Percentage of families living in safe and suitable housing Helen Taylor/ Mike Gogarty Percentage of households living in fuel poverty DPrevalence of mental health disorders among children and adults Barbara Herts/ Helen Taylor ETeenage pregnancy rates Mike Gogarty/ Barbara Herts

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Roles and responsibilities Lead commissioner(s):Mike Gogarty Supporting Commissioner(s):Chris French People in Essex have a healthy life expectancy, Prevalence of healthy lifestyles, Reduced differential in life expectancy across different areas of Essex, Percentage of households living in fuel poverty, Jane Richards Tim Coulson Paul Bird/Helen Morris Helen Taylor, Simon Harniess Barbara Herts People in Essex have a healthy life expectancy, Prevalence of healthy lifestyles, Reduced differential in life expectancy across different areas of Essex, Percentage of children achieving at school, Prevalence of mental health disorders among children and adults, Teenage pregnancy rates Percentage of children achieving at school Percentage of working age people in employment Percentage of families living in safe and suitable housing, Prevalence of mental health disorders among children and adults Percentage of families living in safe and suitable housing Prevalence of mental health disorders among children and adults, Teenage pregnancy rates Ben Hughes People in Essex have a healthy life expectancy Prevalence of healthy lifestyles, Reduced differential in life expectancy across different areas of Essex Maggie Pacini Ian Wake Krishna Ramkhelawon Danny Showell Jason Fergus Jacquline Wells/Juliette Arnold People in Essex have a healthy life expectancy, Reduced differential in life expectancy across different areas of Essex, Prevalence of mental health disorders among children and adults Physical Activity IS

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SUMMARY People in Essex enjoy good health and wellbeing Why is it important for the people of Essex to have good health and wellbeing? ECC are responsible for the health of the public we serve. Health may be seen as a “good” or right for people and is essential if people are to achieve their potential and to live a long life. We embrace the WHO (World Health Organisation) definition of health as a state of physical, mental and social wellbeing not just the absence of illness. What is the strategy? We are able as a whole County Council working with a range of partners to influence, impact and address all the key drivers for health. Our strategy is to recognise a broad definition of public health and to ensure public health considerations inform our commissioning decisions. Delivery of other Outcomes will be key to delivering this one as they are key drivers of health. Additionally we will commission bespoke public health interventions to enable individual s and communities to make the right lifestyle choices together with commissioning clinical interventions that improve health and prevent illnesses. Financial Challenge To deliver the Strategy and to meet any financial challenge will require us to pursue the DH with vigor through all possible routes to secure our fair share of the public health national resource in line with the ACRA formula. Robust and challenging commissioning will continue to secure efficiencies from the grant that will enable progress towards delivery of the strategy and to meeting financial challenge. Delivery in full would be not be possible with a level of funding 40% below our target (sum of distance from target. Savings made to date and a further 20% savings). The securing of the additional grant is therefore critical and is a key strategic action if we are to deliver on both the Outcome and financial challenge Measuring progress Many of the indicators supporting this outcome are infrequently measured and published data, which requires central collection and collation is often several years out of date. Some of the indicators will take some years to change even with optimal interventions and sometimes the link between specific agreed action and the change in an indicator can be hard to exactly ascribe. These issues are common to all preventive interventions. It is proposed that by using interventions where there is a strong evidence based link between that intervention and a given outcome, that delivery of relevant process measures, that can be recorded in real time, is a strong proxy that we are on track to deliver an agreed indicator..

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6 SUMMARY How will the strategy secure improved health and wellbeing for the people of Essex? ECC are responsible for the health of the public we serve. While this was formalised with the shift of responsibility for public health from the NHS in April 2013, it has long been a recognised Council Outcome. Much of what we do impacts on public health whether it is a direct use of the public health grant to commission a specific service or the impact of our broader policies around social care, education, the economy and the environment and communities. Indeed the shift of public health responsibilities to the Council was driven by a national recognition of the critical importance of these factors in enabling good health and wellbeing. We will need to further integrate public health and public health skills and thinking into the organisation to best influence this broad agenda. Good health underlines and is interlinked with many of the other outcomes in our strategy. Material wealth and employment are critical drivers of health and depend on both a vibrant economy and education and learning. Similarly both a sense of control and a safe environment reduce stress and support health. Fundamentally future experience of health starts to be formed from conception and action in early years is crucial to ensuring optimal lifetime health and wellbeing. Links will be made to these outcome strategies, rather than replicating that here. Improving public health will require also a focus on lifestyle choices around smoking. alcohol, diet, physical activity, drugs and sexual health. This will involve both supporting the population to make healthy choices and helping them address unhealthy ones and their consequences. Additionally we must ensure clinical interventions that improve health such a s blood pressure, cholesterol and depression management are systematically available and of high quality. Public Health principles in Essex have been set by a Member’s Reference Group and include a focus on addressing inequalities. This is an important driver in our actions to deliver this outcome. While generally an affluent county, the most deprived area in the whole of England lies within Essex and there are particular vulnerable groups within the Essex population who suffer poor health outcomes. Our strategic response needs to address this. We need to ensure that services are available to the whole population but are particularly targeted at those with the greatest needs who are often less likely to engage. We also need in some areas to have extra bespoke services addressing the specific needs of these people.. This approach is called Proportional Universalism The indicators chosen to support this outcome are varied and reflect the breadth of action required to deliver improved health. It is important however that our actions are focused broadly on delivery of the outcome rather than slavish adherence to chasing what is in effect a sample of indicators. Indeed there are a number of process measures that we should consider in ensuring progress towards this outcome.. Delivery of this strategy will be within the financial envelope of the public health grant. To deliver under financial pressure we must ensure Essex receives its full fair share grant. Success in this work will require close work with other key partners who have a major impact on public health, these include the NHS, district, borough and city councils, schools, police, fire services and voluntary sector groups, local employers and communities. We will need to develop strong new links with DC/BC and City Councils.

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Relationship with other Outcomes and Strategies Delivery of this Outcome is inextricably linked with other agreed outcomes. Longer term health and wellbeing will be delivered through material wealth in the population accompanied by sound lifestyle choices. The former will be delivered through action under our Outcomes around best start and around education and Lifelong learning, both ensuring young people can achieve their potential. The latter will be aided by action in early years and schools around healthy behaviours around diet, exercise, risk taking behaviours and sexual health. Health is similarly linked to the economy and employment so progress around our economic growth outcome will be crucial. It is likely that measurable geographical improvements in reducing measured inequality in areas such as Tendring will ONLY be possible through focussed economic action. Similarly the health of specific vulnerable groups such as those with mental health issues will require action in this area. There are numerous links with our safe communities outcome. Children in care have poorer educational outcomes and lifestyle choices than average and higher levels of poor mental health. Action to deliver reduced numbers of young people in care will therefore improve health. Similarly accident prevention has a link to health and action in this strategy around falls will help with indicators within the safer outcome. Victims of Domestic abuse suffer considerably in terms of both mental and physical health and action in this area will again improve health. High Quality sustainable environment overlaps directly in terms of the fuel poverty indicator. Our environmental Outcome has an indicator around cost of energy to homes, one of the key drivers of fuel poverty. Additionally access to open spaces can impact on physical activity and mental health and wellbeing. “People can live independently and exercise control over their lives “is closely linked especially around the proportion of people who can live independently. The ability to live independently is positive to wellbeing but crucially achieving this will require delivery of the actions outlined in this strategy to reduce vascular diseases and strokes, to reduce mental health issues including depression that predispose to dependency, and to reduce falls, diabetes, and lung diseases related to smoking.

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Strategic Actions ~ Overarching ActionLeadResourceIssues addressedTimetable Members and Officers will work with partners and MPs to ensure Essex receives its fair share public health grant Joanna KillianPH grantOptimise baseline resource required to deliver strategy in financially testing environment Deliver by April 2015 Public Health Tier 4 staff to be fully engaged in all strategic roll out Mike GogartyPH grant– this is resourced within the current MTRS Recognise and optimise ability of all Essex outcome strategies to impact on public health. Ensure opportunities for public health solutions in other strategic areas are identified Commence May 2014 Develop public health skills of commissioning workforce through new Commissioning Academy Maggie PaciniPH grant - this is resourced within the current MTRS Enable recognition of impacts on public health of commissioning activity. Ensure skills such as evidence based practice underline commissioning decisions September 2014 Re establish fit for purpose public health links to districts and boroughs Mike GogartyPH Grant - this is resourced within the current MTRS DC/BC have key role and interest in ensuring local public health. We need to align and support this work. Ability to do this is a gap in T2. August

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9 Quality Criteria The discussions that have taken place with operational teams on future plans; This strategy will largely be delivered through procurement from external providers. While they have not as yet had sight of the strategy, they are aware of thinking around specific elements relevant to them. Where there is an implication for ECC operational colleagues, they too have been aware of discussions eg Adult Ops colleagues in discussing involvement of social workers in screening older people for depression. The research and analysis (e.g. benchmarking) that has been carried out to support the proposed strategic direction; Where available national data has been used related to the Indicators. In a number of areas this has been insufficient to allow a trend to be developed so alternative measures have been used where historic trend is available to set direction. All proposed actions are evidence based. The range of commissioners and members who have been involved in the development of the Strategy document; The document has been shared with and benefitted from input from a wide range of People and Place commissioners including leads for all other Strategic outcomes as well as a range of Tier 3 and Tier 4 managers. It has been developed throughout with input from Cllr Naylor and has been shared with a number of cabinet members including Cllr. Madden, Aldridge, Bentley and Gooding. It was also presented to Member’s Reference Group although attendance was low. Externally It has been shared with CCG Accountable Officers and NHSE Executives with comments received from some. It has been shared with a number of DC/BC and there has been a presentation to Members in Tendring DC. Comments received from 3 CCGs and Chelmsford City (to date) have informed the text. Governance arrangements for taking decisions on the issues highlighted by the strategy – in cases where partnership governance is an issue, this should be accompanied by an assessment of how strong the partnerships are, and what we will do to strengthen them; We need to ensure the benefits of a County Council approach to public health are fully realised without losing the historic links to NHS commissioning and the need for local solutions in many instances.. This will involve ensuring the County Council as a whole recognise and embrace their public health role and that is recognised in our governance structure and system. We need to recognise when a Essex wide approach to commissioning makes sense and when an integrated approach with resources aligned to CCGS is the right solution and consider in each case the appropriate governance arrangement. The direction of travel for ECC and partner activity; Links with CCG colleagues and public health have been well maintained since the transfer of Public Health to ECC. Links to DC/BC/city while initially strengthened have slipped during T2. Going forward, if we are to best deliver this strategy we will need to re establish vibrant. Proactive and locally focused public health links with DC/BC/City. We will retain and develop our links with the Police and Crime Commissioner and with provider representative bodies such as the LMC.

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10 The high-level timetable for the strategic actions proposed This is within the text How the Strategy could help ECC to address its future funding gap. The Strategy could help ECC funding gap through both driving efficiencies from use of the public health grant through delivering enhanced services while challenging the market hard. The timescale for this will be determined by the agreed length of existing contracts inherited from the NHS and will not have a full impact until 2016/17. The strategy will also deliver savings through reduced demand on services in both ECC and CCGs with a short term gain possible within 1-2 years around initiatives around depression and blood pressure management.

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Strategic analysis and insight – the story behind baseline position People in Essex have a healthy life expectancy This is a new composite measure looking at both life expectancy and self assessed sense of health from survey Healthy Life expectancy, Essex , Males 64.7, Females 66.7, England Males 63.2, Females 64.2 As we have no trend data on this, below looks at total rather than healthy life expectancy

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People in Essex have a healthy life expectancy The Baseline and the Story behind it. While the chosen indicator is Healthy Life expectancy, this is a new measure with no trend data. We therefore use life expectancy to understand context and to set trajectory. We have been seeing an increase in Life expectancy over recent years at Essex level. While still ahead of England, the improvement has been relatively poorer of late with levels now below Regional average. This is likely to reflect particular issues in more deprived districts and boroughs. (see below) Drivers include broad determinates such as material wealth, employment and poverty and these are in turn are driven by education and the economy as well as access to benefits. Other drivers are healthy lifestyle choices as well as preventative and curative clinical interventions. Changes to the drivers may take decades to impact on this measure eg Education, others especially clinical ones, as well as some lifestyles changes such as stopping smoking and undertaking physical activity may act quicker. Key causes of death, as elsewhere in the developed world, remain cancers and cardiovascular disease including stroke with ill health additionally being caused by mental health issues together with frailty in the aging population. We would expect to see continuing improvements in this measure as the economy improves and as we develop better public health services. It must be remembered however that the key determinate of health is age and that an older population will tend to suffer poorer health than a younger one. It is likely then that absolute need for health and social care services will continue to grow as the population profile shifts to include a higher proportion of older people.. However we expect as the population ages, the health of an older person in the future will be better than that of an older person of the same age now mitigating to some extent the impact of aging on care needs. With respect to healthy life expectancy we need especially need to consider the impacts of frailty, mental health issues, and stressors such as deprivation, debt, fear of crime and social isolation. These overlap with Outcomes around Safety, the Economy and Independence. The Curve we need to Turn We would wish to see a proportional increase in the Life expectancy in Essex similar to that seen elsewhere in the Region and nationally. This is not a quick win and data is collected historically and takes several years to become available. The most recent data shows where we stood 3-5 years ago and given the often long term nature of interventions, it may take several years before any impact becomes visible. We need to track progress then through clear process and impact measures and these will link to the raft of actions we take to deliver this indicator that are outlined in the Strategic Action section.

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Reduced differential in life expectancy across different areas of Essex

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The Baseline and the Story behind it The indicator above looks at geographical variation across DC/BC which is easy to measure. We also can and will look at the differences between more and less deprived small areas (MSOAs). However, in addressing inequalities we need to also look at differences between certain vulnerable groups who experience inequalities in life expectancy including people with mental health issues, people with learning difficulties, gypsy and traveller groups and people who are homeless. These will be hard to measure locally but this must not detract from our endeavours to address these inequalities. Clearly life expectancy (LE) is related to deprivation. The populations who suffer most material deprivation, and unemployment have lowest life expectancy. Separately from this issue, they also often make poorer lifestyle choices and find it harder to engage with services. All these issues need to be addressed. While as expected from national trends most areas and groups in Essex are living longer lives, this is worryingly not true in Harlow and especially Tendring were LE is shortening. Similarly Rochford has not seen an increase ( but higher starting point). The issues in Tendring in particular highlight the increasing deprivation of the area. It must be remembered the LE seen is the result of decades of population experience of broader, lifestyle and clinical factors rather than quick impacts and where there is population movement, those dying now in the area may have spent most of there lives elsewhere and have experienced the socioeconomic impacts prevalent in that area. The Curve we need to turn We wish to see continued improved LE in all areas but this indicator is around reducing the differences between areas. We will need to start as well to look at changes across deciles of deprivation but in the absence of historic baseline data, setting a trajectory will be problematic although given data lags we will likely have more historic data available to help inform this before we need to demonstrate the long term impacts of interventions described in this strategy. In the interim we can look at DC/BC data as attached. For Tendring (and Harlow) we would expect to see further deterioration, given the historic nature of data and time taken to intervene,for several years to come before we can slow and reverse this trend. Early success will be through clinical activity and some lifestyle action. It is recognised these populations are at risk due to many years of deprivation and quickest action will involve addressing clinical risks such a high blood pressure and cholesterol followed by tackling lifestyle factors such as smoking. Addressing the broader underlying determinates takes decades to see an impact and evidencing this depends on a static population. An influx of people from deprived London areas to Tendring or migration out of professional groups would lead to continued deterioration in LE. Interventions need to address broad societal, lifestyle and clinical issues. The principle of proportional universalism will be followed with increased weighted access to the full range of interventions offered elsewhere as well as bespoke local interventions Partnership work with the local district s/ borough and CCGS as well as local voluntary sector groups will be crucial

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Delivering improved public health needs to recognise the breadth of intervention required. Some will be narrow and clinical where intervention prevents death and disability eg blood pressure management. Some will require specific interventions to improve lifestyle choices eg smoking services, others will address the wider societal context to improve lifestyle choices eg trading standards and highways. More fundamentally we need to optimise health through improving material wealth through educational attainment and economic growth and through access to benefits to those who need them. As well as tackling the health needs of the whole population, we also need to address unacceptable inequalities in health across Essex both geographically and within vulnerable groups. This will involve Proportionate Universalism, a term derived in the Marmot report. It involves additional focus of the interventions described above targeted at the most vulnerable eg extra resources for health checks in deprived populations as well as specific initiatives directed at vulnerable groups eg ECTU (Essex County Travellers Unit,) Reach Out project in Jaywick. In order to turn the curve we need to address people's attitude and the culture towards health and wellbeing. Individuals need to be encouraged to take responsibility for their health and the wider community also need to take some of that responsibility. There is a need to address some of the wider issues relating to the food, drinks and tobacco industry. Key issues for public health commissioners will be:- Address the high level of heart and stroke deaths and disability through commissioning evidence based preventive clinical interventions Address morbidity related to mental health through improving lifestyle risk factors and access to screening, prevention and management in those who suffer, and addressing broader issues through improving employment and housing in this group. Address common causes of ill health in older people including falls prevention, continence care, social isolation, depression and dementia. Address the needs of vulnerable groups including those who misuse substances, prisoners, travellers, the homeless, people with learning difficulties, care leavers and looked after children Improve lifestyle choices through services and system changes to support choices and address issues around smoking, alcohol, physical activity, diet, substance misuse and sexual health using universal and targeted interventions. However the above will be of limited value without full involvement of People and Place colleagues to:- Optimise parenting and early years support Improve educational attainment Support the economy and reduce unemployment Support vulnerable groups including through floating support, ECTU, benefits advice, and social care input Ensuring a safe environment, safeguarding vulnerable people, reducing domestic abuse and other crime Developing an environment conducive to healthy choices around exercise and diet. Issues to address in order to turn the curve Addressing educational attainment will be key. Evidence suggests that educational performance in the more affluent areas is even better than would be expected given the wealth of the area but educational performance is even worse than expected given the level of affluence in the more deprived areas. This will drive a long term INCREASE in inequalities if not addressed through focussed action on areas performing less well

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Prevalence of healthy lifestyles:- Smoking Prevalence

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17 Reduced Smoking Prevalence The Baseline and the Story behind it Smoking is the biggest preventable cause of ill-health, disease and death and the single most important lifestyle factor affecting health inequalities. In Essex the adult smoking prevalence is 18.7%, but this varies across the localities and between those in the general population and those in routine and manual groups (R&M) with prevalence rising as high as 39% in R& M groups in Colchester We have seen a decrease in smoking prevalence over recent years at an Essex level, but this has slowed recently. Essex still has lower rates than the national prevalence figure (20%) and the regional figure of 19.6% Despite witnessing a decrease in overall prevalence, evidence suggests that certain population groups should be targeted. There needs to be a focus on increasing the number of quitters from those population groups who face the greatest barriers to giving up smoking –R&M groups –Children & young people under the age of 19 –Black and Minority Ethnic Groups Nationally 4% of year olds are regular smokers and this is replicated in Essex. Smoking in pregnancy is associated with poor pregnancy outcomes and needs special focus. There is a strong link between smoking and deprivation and a danger that a single universal approach will better tackle those in more affluent areas. The principle of proportional universalism therefore needs to apply with services targeted in the most deprived MSOAs Particular vulnerable groups such a s people with mental health issues have high rates of smoking and will benefit from particular focus. The Curve we need to turn We wish to see a year on year reduction in smoking prevalence. We want to see a reduction in smoking prevalence in the population groups outlined above. Issues to address in order to turn the curve In order to achieve reduced prevalence there needs to be a combination of a wider tobacco control agenda as well as providing local Stop Smoking Support Services (SSSS) Addressing inequalities will in part be achieved by targeting SSSS in the most deprived areas and at the relevant population groups. The principles of proportional universalism will be followed.

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Obesity in Adults and Children 18

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19 Obesity in Adults and Children The Baseline and the Story behind it Adult obesity continues to rise nationally, but the rate of increase appears to be slowing. The causes and drivers are complex and linked to changes in lifestyle linked to diet and physical inactivity. Around two thirds of adults are overweight or obese. Prevalence within Essex is similar to England, however, there are variations between local authority districts. PHE data in February 2014 shows adult overweight and obesity levels within Essex ranging from 62% in Chelmsford to 73% in Castle Point. Although a comparatively small sample size with a wide confidence interval, this places Castle Point within the highest 10 districts in England. Current adult weight management services within the county, previously commissioned by the 5 Essex PCTs vary widely, with inequity of provision between areas. Some areas have specialist services for morbidly obese adults only, others have lifestyle weight management services for the overweight and obese, whereas Castle Point and Rochford have no services for adults. Child obesity measured through the NCMP programme shows a flat trend in recent years for both age groups following a strongly rising trend in recent decades. This is in line with national trends. Current child (family) weight management services, like adult services similarly show variations in provision, with some areas having none. The Curve We Need to Turn We need to reverse the rising tide of obesity in adults. Preventative initiatives are often very long term and require action in childhood to impact on subsequent generations. We can expect little positive change to the population for some years but will see process measures demonstrating better access to weight management support and outcomes Issues to address in order to turn the curve The establishment of a clear county-wide obesity intervention pathway is a priority. A key element is the further development of partnership working with Clinical Commissioning Groups, focusing on the overweight or those at risk of being overweight, as opposed to the whole population. Current geographical inequity of adult weight management service needs to be addressed through the commissioning of a county-wide Tier 2 model, aligned with CCG Tier 3 provision for the morbidly obese. Interventions to ensure county-wide equitable provision of child (family based) weight management services, linked closely to the 5-19 pathway is an on-going priority. Obesity interventions need to be closely aligned with interventions associated with increasing physical activity. Specific commissioned services need to be supported by a raft of population wide activities around breast feeding, increased physical activity, healthy schools, school meals, improved access to healthy food choices and reduced access to unhealthy, options and both population and focussed education around cooking and eating.

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Physical Activity 20

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21 Physical Activity: Increasing levels of Physical Activity in Essex and its associated boroughs The Baseline and the Story behind it Evidence shows only 37.1% of Essex residents participated in at least 4 sessions of at least moderate intensity activity for 30 minutes in the previous 28 days. Also, 44.7% of residents take part in no sport or active recreation (NI8 APS ). Physical inactivity is a significant, and independent risk factor for numerous physical and psychological conditions. It is associated with a greater risk of developing coronary heart disease, osteoporosis, hypertension, stroke, non-insulin dependent diabetes mellitus, obesity and depression. People who are physically active reduce their risk of developing such long-term diseases (coronary heart disease, stroke and type II diabetes by up to 50%, and premature death by 20-30%). On average, an inactive person spends 38% more days in hospital than an active person, and has 5.5% more GP visits, 13% more specialist service and 12% more nurse visits than an active person (Sari, 2008). Helping and supporting inactive people to move to a moderate activity level will produce the greatest reduction in risk of ill health and will contribute to reduction in risk of coronary heart disease and obesity, hypertension, cancer, osteoporosis, depression and anxiety (Physical activity in childhood has a range of benefits including healthy growth and development, maintenance of energy balance, mental well-being and social interaction. (Department of Health, 2004) Increasing the amount of physical activity/ sport in a variety of settings, from active travel/ recreation and sporting environments is shown to create behavioural change and embedded lifelong participation, passed down into the next generation. Increasing physical activity levels is a key component of reducing cardiovascular disease (CVD), cancer and diabetes; and obesity. Interventions focusing on behaviour modifications provide short-term benefits. Educating people and informing their lifestyle choices by promoting opportunities to participate and communicating the many health benefits of an active lifestyle is key. The current evidence base recognises that for long-term benefits social, structural and economic factors need to be addressed, a range of complex factors combine to influence levels of sedentary behaviours, physical activity and sport participation. The curve we need to turn We as elsewhere are starting from a very low base. We want to improve the numbers taking ANY exercise as well as the numbers undertaking nationally recognised amounts. Progress will be slow at best a percentage point a year Issues to address in order to turn the curve Place - Targeting environments to encourage and facilitate physical activity in public open space, cycle paths, schools, sports facilities & buildings, safer roads and communities. People - Targeting groups with levels below recommended guidelines, eg Children and Families (who do not have a familial culture of physical activity), people living in areas of deprivation, Older people, Women, Black and Minority Ethnic Groups, people with learning disabilities and targeted early years settings, primary and secondary schools. Essex requires a multi-agency approach to develop and direct holistic physical activity and sport. Active Networks action plans should incorporate multi agency services for evidence based universal interventions (Tier 1) and targeted lifestyle interventions (Tier 2). Active Essex will support and lead Active Networks to work with CCGs to maximise the opportunities at Tier 2. Tier 1 and Tier 2 commissioned interventions to ensure impact on outcomes & indictors through performance measures. District, Borough and City Councils are key partners in this endeavour.

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22 Alcohol

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Hospital Admissions due to Alcohol The Baseline and the Story behind it The indicator above looks at the rate per 100,000 of admissions to hospital. This is calculated by applying certain criteria to Hospital Episode Statistics in relation to 47 conditions of which 13 are wholly attributable to alcohol consumption and 34 partially attributable These include hypertensive diseases, mental and behavioural disorders and cardiac arrhythmias. In 2010 alcohol use was the third leading risk factor contributing to the global burden of disease after high blood pressure and tobacco smoking Average alcohol consumption has gradually fallen in many OECD countries between 1980 and 2009 with an average overall decrease of 9%. The United Kingdom however, has seen an increase of over 9% in these three decades. Additionally drinking in pregnancy is associated with increased fetal and infant mortality and morbidity including fetal alcohol syndrome. In England in 2011/12 there were 49,456 hospital admissions for alcohol-related liver disease, which is the only major cause of mortality and morbidity which is on the increase in England whilst decreasing in other European countries The most effective strategies to reduce alcohol-related harm from a public health perspective include, in rank order, price increases, restrictions on the physical availability of alcohol, drink-driving counter measures, brief interventions with at-risk drinkers, and treatment of drinkers with alcohol dependence The picture in Essex closely follows that seen nationally with some occasional variations. The curve we need to turn Following several years of seeing significant rates of increase in Alcohol related hospital admissions we would be looking to see a reduction in the rate of increase before reducing the rate This is in the main due to the fact that many of those conditions considered will have significant delays in presenting themselves and effects of local investment and development have a reasonably long “lead time” before impact. Is seen. Issues to address in order to turn the curve Historic investment locally in the provision of many interventions and treatment services has been patchy and service provision and service utilisation rates are significantly below those recommended by the Department of Health. Early wins will be seen by monitoring a number of indicators and performance measures and developing a system of support and treatment that starts to meet the national minimum expectations and builds towards matching the system provided to address drug misuse issues Building on the work with Trading Standards in relation to age related sales and supply of alcohol and with District/boroughs around work on Licensing, Community Safety, e.g. alcohol out reach, licensing traffic light system, reducing the strength project Commissioning a treatment system that addresses issues of dependence and also engages with hazardous and harmful drinkers at earlier stages Developing a range of Brief Interventions strategies through ALL public facing provision and multi media/platform applications Developing an Alcohol Harm Profile for Essex and acting on the intelligence gathered therein to impact on supply through licensing 23

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Successful completion of drug treatment 24

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Successful completion of drug treatment The Baseline and the Story behind it Drug misuse is a complex issue. While the number of people with a serious problem is relatively small, someone's substance misuse and dependency affects everybody around them. The most harm is associated with dependence in relation to Opiates (Illicit, prescribed and Over the Counter (OTC) ) and this is the major focus of treatment activities. In Essex there are predicted to be in excess of 4500 Opiate users (as calculated using the Glasgow Estimate from Public Health England/DH). Measuring penetration into this population and the numbers of All Adults and Young People engaging with effective treatment allows us to see how our services and the system is engaging with drug users across the county. It is shown that treatment works (various data and research products provided by the National Treatment Agency/Public Health England) and successful completion of drug treatment (within a recovery focussed system) is a useful measure to indicate a reduction in the harm caused by drug misuse. In time we will also be measuring the numbers exiting treatment in a planned way and not representing to treatment within six months of discharge thereby providing more evidence of the reduction in harm. The curve we need to turn As we have seen a significant increase in the numbers accessing and engaging with effective treatment we have seen this impact upon the “proportion” completing successfully. We have noticed a slight increase in the numbers leaving treatment in an unplanned way. Issues to address in order to turn the curve We need to ensure we are working with commissioned treatment providers to reverse the decline and the curve we need to turn is to see an increase in the proportion of those in treatment completing successfully. Work is already underway to review data collection and reporting and this has seen us halt the decline and we now need to target our joint efforts to ensure that clients are being managed effectively into recovery and “exited” from structured treatment more effectively and into recovery support provision. 26

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Life Satisfaction Rates Life Satisfaction Life Satisfaction is determined by a range of interlinked factors as well as levels of expectation. Improvements to this trajectory will be sought and delivery will depend on overall progress across all outcomes in this strategy. The curve we need to turn Data above suggests a decline in life satisfaction in Essex while nationally satisfaction is improving. We wish to reverse this curve and see a rate of improvement in excess of that seen nationally to regain our relative difference in improvement.

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n People In Essex have a healthy life expectancy Life satisfaction rates (ONS condition of wellbeing) Percentage of Essex residents who consider themselves to be in good health Strategically the above will be addressed through a combination of identification and management of people at high risk or with conditions, addressing lifestyle (discussed below) and addressing broad determinates.. Key to success is to develop and deliver a public health strategy that recognises:- The Broad range of determinates that affect health, and hence the wide range of areas in which ECC can influence outcomes The role of all agencies, communities and individuals in delivering this agenda The need to balance local, Essex and national solutions The need to recognise process and output measures as relevant as we strive to achieve often very long term improvements in outcomes The need to balance short term health gains and productivity with initiatives delivering crucial health gains often decades from now The actions outlined below are key initiatives in delivering these outcomes Strategic Actions (given existing resource envelope) Broad Determinates School Achievement (below and in our Best start in life and education and life-long learning commissioning strategies), Employment (see below and our commissioning strategies for economic growth), Giving children best start ( see our best start in life commissioning strategy), Safe community ( see our safer communities commissioning strategy)

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Strategic Actions ~ Management High Risk ActionLeadResourceIssues addressedTimetable National cardiovascular Health checks programme and local senior health checks and atrial fibrillation programmes. Chris FrenchPH grant – this is resourced within the current MTRS Short to medium term reduction in heart attack and stroke deaths and disability from stroke. £2.1m savings (to be delivered in 2014/15 and 2015/16)are built into the Adult Operations care budgets with the MTRS predicated on delivery of this action. In place, extension required Depression in older people. Many older people have depression and are not identified or managed. Ian WakePH grant – this is resourced within the current MTRS This will identify people with depression and allow best management Potential £0.5m of benefits in year 1 and 350k recurrently not already within the MTRS - realisable in our independent living commissioning strategy September 2014 Commission a range of services to prevent alcohol misuse, Ben HughesPH grant– this is resourced within the current MTRS Identify and reduce harm in those drinking to harmful levels and develop services for dependent drinkers £1.3m savings (to be delivered between 2014/15 – 2016/17) are built into the Adult Operations care budgets within the MTRS predicated on delivery of this action. From April

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Strategic Actions ~ Management High Risk ActionLeadResourceIssues addressedTimetable Commission evidence based falls services Maggie PaciniPH grant– this is resourced within the current MTRS Identify those at risk and prevent falls and the harm that ensues. £200,000 savings (to be delivered in 2014/15 are built into the Adult Operations care budgets within the MTRS predicated on delivery of this action. From April 2014 Ensure best identification and management high blood pressure Ian WakePH grant- funding needs to be found from PH grant, year 1 cost, 1.4m, year 2 cost approx. 800k, no further recurrent cost Reduce stroke and other disease through better management high blood pressure From April 2015 Work with CCGs to secure evidence based continence services Krishna Ramkhelawon PH grant – this is resourced within the current MTRS Manage and reduce the harm caused by incontinence both to those who suffer and their carers. £1.2m savings (to be delivered between 2014/15 – 2016/17) are built into the Adult Operations care budgets with the MTRS predicated on delivery of this action. Full implementation 2015, part implementation through

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ActionLeadResourceIssues addressedTimetable Work with CCGs to ensure best treatment of strokes. Maggie PaciniPH grant – this is resourced within the current MTRS Ensure people receive the best possible evidence based care after a stroke to ensure best recovery. £2m savings (to be delivered between 2014/15 – 2016/17) are built into the Adult Operations care budgets within the MTRS predicated on delivery of this action.. From April 2014 Addressing the issues above will deliver short and medium term gains in delivering the commissioning strategy for helping people maintain independence. The total savings targets built into the MTRS within the Adult Operations budgets up to 2016/17 is £6.5m. This is predicated on delivery of these key actions. From depression initiative above we could save 500k in year 15/16 and 350k recurrently From Hypertension initiative above there is potential to deliver an additional £1.5m subject to identifying non-recurrent set up costs. 31

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32 Reduced differential in life expectancy across different areas of Essex ActionLeadResourceIssues addressedTimetable Value of contracts will be weighted to take account of deprivation eg Healthy Schools Programme, Jane Richards, Ben Hughes, Chris French. PH grantMore resource and focus in areas of greatest need with emphasis on agreed deprived groups through proportionate universalism Sept 2014 and as contracts end Resource Specific Targets around numbers of smoking quitters from deprived wards Chris FrenchPH grantApril 2014 Differential remuneration for Health Checks undertaken in deprived groups Chris FrenchPH grantOngoing Bespoke Health check services aimed at vulnerable groups Chris FrenchPH grantReduced cardiovascular risk, diabetes, obesity and strokes in defined hard to reach groups Increased focus from 2014 Targeted obesity and physical activity services for vulnerable and high risk groups Jane Richards, Jason Fergus PH grantFrom Sept 2014 Targeting lifestyle support through volunteer health champions at high risk groups including people with mental health issues Chris French, Ian Wake PH grantFrom Sept 2014 Targeted services via third sector eg Reach OutJane Richards, Ben Hughes, Chris French PH grantReducing impact broad determinates including debt Ongoing, ideally role out 2015 Bespoke services for vulnerable groups eg ECTU, LD football, sexual health and mental health support for Looked After Children Jane Richards, Ben Hughes, Chris French, Ian Wake PH GrantReduce risks of ill health and social isolation in very high risk and hard to reach groups Continue to develop 2015 All the above are resourced within the existing MTRS. The savings being delivered against these actions relate to re-procurements. There is a total Public Health procurement saving within the MTRS of £2.1m up to 2015/16.

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33 Prevalence of healthy lifestyles ActionLead Resource Issues addressedTimetable Smoking Cessation services and broader action on tobacco. Chris FrenchPH grantReduce harm from smokingContinue to develop, refocus 2014 Obesity initiatives. This needs to include both ensuring a county and partner wide approach to addressing weight issues as well as commissioned bespoke tier 2 weight loss services. Jane RichardsPH grantReduce harm due to excess weight and obesity in the Essex population including those at most risk. Sept 2014 Improved physical activity. This needs to include both ensuring a county and partner wide approach to improving physical activity as well as commissioned bespoke services to improve physical activity in high risk groups. Also the current actions within the Sustainable Environment outcome strategy Jason FergusPH grant, ECC Baseline Funding external funding for projects Improve health through increased physical activity impacting on physical and mental health Sept 2014 Sensible alcohol use,education, prevention and management. Working with Community Safety Partnerships Ben HughesPH grantReduce harm to individuals and population through alcohol misuse Ongoing, developments from April 2014 Sexual health services. We will develop a range of in line with best practice that are accessible and provide a range of support, advice and treatment to all. Jane RichardsPH GrantEnsure positive sexual health and reduced related disease. Sept 2014 Commission a range of evidence based services for people who Misuse Substances, developed with input from service users Ben HughesPH grantEnsure those who need these services are able to access them reducing harm to population From April 2015 Work with Schools colleagues to optimise impact of Healthy Schools on lifestyle choices Chris FrenchPH grantImprove healthy Lifestyle choices in young people April 2014 Work with employers including key public sector orgs. to support healthy lifestyles Chris FrenchPH grantImprove lifestyle choices of people at work Sept 2014 The savings being delivered against these actions are in relation to re-procurements. There is a total procurement saving within the MTRS of £2.1m up to 2015/16 – There is potential for over delivery against this target by £1.2m that could help mitigate a 10% resource reduction

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Percentage of Children Achieving at school The Baseline and the Story behind it Health is in large part determined by socio-economic factors throughout life. These factors including employment and housing are in large part related to material wealth and this in turn is driven by educational attainment. Educational outcomes in Essex (measured by GCSE results) are now just above the national average in Essex and Statistical neighbours and are improving. Evidence suggests that educational performance in the more affluent areas is even better than would be expected given the wealth of the area but educational performance is even worse than expected given the level of affluence in the more deprived areas. This will drive a long term INCREASE in inequalities if not addressed through focussed action on areas performing less well. School readiness levels in Essex have been poor but again are improving with most recent data on readiness at the end of reception year now slightly above the England average at 52.5%. There is clear evidence that early years development in large part determines future academic progress and high levels of school readiness are essential The high proportion who are not school ready (nearly 48%) suggests action needs to be directed universally to families as well as the specific focus needed on those with greatest needs. This requires universal support for strong effective parenting and preschool education. Essex is far from homogenous with some areas of real excellence and others where educational attainment is poor. Tendring schools are currently doing less well relative to other areas of Essex. Areas which used to have poorly performing schools, eg. Basildon and Harlow, which have had recent ECC support have improved. Details of what needs to be done and the action planned both to address school readiness and parenting is described through our “Children in Essex get the best start in life” strategy and action to improve educational attainment within schools is described through our “People have aspirations and achieve their ambitions through education, training and lifelong-learning” commissioning strategy. The Curve we need to turn Essex wants to be in top quartile nationally for standard national benchmarked data for educational attainment. These are described in detail through our commissioning strategies for Best Start in life and for education and life-long learning Issues to be addressed to Turn the Curve These are described in detail through our commissioning strategies for Best Start in life and for education and life-long learning 35

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36 Strategic Actions ~ Percentage of Children Achieving at school ActionLeadResourceIssues addressedTimetable Actions around improving parenting and nursery education addressed under Outcome for best start in life Chris MartinChildrens’ commissioning improve school readinesssee Commissioning strategy for best start in life Actions around Educational attainment is discussed under Outcome for education and life-long learning Tim CoulsonSchools BudgetImprove educational attainment see Commissioning strategy for education and life-long learning

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Percentage of working age people in employment

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Percentage of Working Age People in Employment The Baseline and the Story behind it Employment is absolutely key to health. Studies have shown that unemployment has a serious detrimental impact on all aspects of the physical and mental health not just of the person who is unemployed but on their whole family. This essential indicator of health and wellbeing will be tackled under our “Sustainable economic growth for Essex communities and businesses” outcome. There are particular issues around levels of unemployment in population sub groups. Much of the harm to health in people with mental health issues is around their high levels of unemployment that is not directly related to the mental health issue. Linked to the modest rate of economic growth in recent years there has been relatively slow growth in the number of jobs in Essex. Key locations for growth are Basildon, Braintree, Chelmsford, Colchester and Harlow. Key sectors are advanced manufacturing, low carbon and renewables, logistics, life sciences and healthcare, digital, culture and creative. The employment rate for December 2012 (73.9%) showed a continued trend of improvement since It was slightly down on the East of England region (74.6%), but compared relatively well to Kent where employment rates continue to fall. The Essex figure was also greater than the National rate (70.9%). The unemployment rate also increased in Essex in 2012 (7.2) compared to 2011 (6.7) reversing the improving picture identified between 2010 (7.3) and 2011 and bringing the unemployment rate back to just below 2010 levels. By contrast, East of England authorities showed general improvement in 2012, compared to a period of decline in Overall, whilst there may have been some year on year variation in results the East of England picture suggests that unemployment rates in general are back in line with Nationally 2012 rates (8.0) were higher than 2010 (7.8) although down slightly on 2011 (8.1). Between July 2012 and June 2013 Harlow (9.8%), Tendring (9%) and Basildon (8.9%) had the highest unemployment rates of all the Essex districts. Unemployment hotspots in parts of the county are also worst affected by youth unemployment. The highest unemployment rate in Essex for Jul 2012 to Jun 2013 was for the age group 16 to 19 years (29.2%). This was not significantly different from the East of England and England rates. Nearly 8, year olds in Essex are claiming Job Seekers Allowance as of May an increase of 12% since the same time last year. A further 6,720 are claiming other out of work benefits. The actual number of unemployed in Essex increased significantly from 2011 (46,900) to 2012 (51,300),recording the highest level for many years. To sustain economic growth in the context of substantial demographic growth between 2014 and 2021, we will need to secure an additional 33,000 jobs and an additional 34,000 homes 38

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The Curve we need to turn This is described in detail under our outcome for economic growth Job growth and employment rates have begun to rise and we need to continue to support this direction of travel. Continue efforts to reduce NEET figures under economic growth and education and life-long learning outcomes There is a need to help people with mental health issues to keep or find work. Reduction in health inequalities between geographic areas especially Tendring requires economy focused action and is unlikely to succeed without this. Issues to address in order to turn the curve This is described in detail under our outcome for economic growth 39

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40 Strategic Actions ~ Percentage of Working Age People in Employment ActionLeadResourceIssues addressedTimetable Detailed action is described through our economic growth commissioning strategy Paul BirdFinancials in relation to these actions are addressed in our Economic Growth Commissionin g Strategy Improve employment opportunities so improving health across population including vulnerable groups and high risk geographical areas. As per our Economic Growth Commissioni ng Strategy

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Percentage of families living in safe and suitable housing The Baseline and the Story behind it Homelessness, the threat of homelessness and poor quality accommodation can have a serious health impact on health and wellbeing. Unsuitable housing can have a detrimental effect on health (e.g. hypothermia), exacerbate ill-health (e.g. from dampness), pose risks (e.g. falls or accidents) and can cause anxiety and stress (e.g. fear of becoming homeless or overcrowding) leading to mental health conditions. Numbers of homeless people will be a key measure to demonstrate the Council and partners’ commitment to reduce homelessness. This should include the number of housing brokerage supported by social workers to cater for vulnerable groups (e.g. people with learning disabilities, sensory or physical impairments). Numbers of statutory homeless as attached is not the full picture. Many people will not be included such street homeless and people who are “sofa surfing” with friends or relatives. Safe and Suitable Housing should include [i] Rented properties – advice on housing condition [ii] Housing Association support [iii] Supported and Sheltered accommodation [iv] Safety at Home and bogus caller support – fire, fall/accident prevention, DV, Telecare, Listed traders [v] Homebuy advice – debt prevention, mediation [vi] Home adaptations – older/disabled people [vii] Energy advice – heating, grants, tariff switching, low income families [viii] Homelessness [ix] Affordable Housing development There are particular serious needs in those who are street homeless. These have been discussed in our Homeless needs assessment. These include high levels of mental health issues, alcohol and substance misuse and poor access to primary care services. Families in temporary accommodation with insecure tenure face a different set of needs related to overcrowding and safety as well as a lack of continuity with an impact upon attachments to the community and fragmented school experience People present as homeless to Districts and Boroughs. We need to ensure their needs are appropriately met. We need to work to prevent housing crises especially in vulnerable groups including ex offenders, people with mental health issues or who misuse substances, people with a learning disability, care leavers and those living chaotic lives. We need to ensure suitable quality private rented accommodation Local Authorities can now discharge their housing responsibilities through private sector rented housing. People placed will almost certainly have less security of tenure, and possibly fewer rights compared with social housing. The quality of private rented housing is also variable, especially in regards to structural stability of houses, dampness, safety and efficiency of heating. Any increase in mortgage repossessions should be viewed as a proxy measure for those at risk of less safe and suitable housing.

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The curve we need to turn We need to develop our understanding of available data. Discussion with partners and stakeholders on which sub cohorts of the population are at greatest risk will be important. We will reverse the increase seen recently in statutory homeless We will reduce the number of people with mental health issues at risk of homelessness Issues we need to address to Turn the Curve This is crucially the role of Districts and Boroughs. We need to ensure an effective forum for addressing housing issues with providers and housing strategy leads within the districts. Establish a COG to look at and address issues around housing and homelessness Work with the Domestic Abuse COG will ensure appropriate accommodation and support options for those suffering DA. Regarding refuges, we need to pay specific attention to supporting families at risk through the locality options that are available, all of which will impact upon young children and the quality of school preparedness We need to ensure acceptable quality of private rented accommodation. This will include the ECC Private sector landlord accreditation scheme We need to consider with partners the management and allocation of Disabled Facilities Grants (DSGs) in supporting families caring for a disabled loved one, to have the optimal environment to learn and to live more independently. Interventions include commissioned floating support service which directly supports vulnerable adults with housing needs, eg debt liaison, discussion with landlords, people at risk of domestic violence as well as the Council using its legal powers to protect tenants from harassment and unlawful eviction. We will develop a strategic approach to the prevention and management of homelessness including a focus on risk groups such as people with mental health issues We need to ensure the right level of provision for affordable housing, housing (e.g. ‘extra care’) to support people live more independently and the appropriate level of residential care home. We need to Increase in the number of landlords claiming the Landlord’s Energy Saving Allowance (LESA) which will be an indication that they are making energy saving improvements 43

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44 Strategic Actions ~ Percentage of families living in safe and suitable housing ActionLeadResourceIssues addressedTimetable In partnership with District and Borough Councils we will develop and implement a homelessness strategy and action plan Simon Harniess Housing BudgetCoordinated approach to homelessness across agencies March 2015 Review the existing housing strategy for those with additional needs Simon Harniess Housing Budgetensure plan remains relevant. This will link to our Independent living commissioning strategy September 2014 Work with DC and BC around ensuring a flexible approach to people who are chaotic Simon Harniess Housing BudgetPrevent clients losing tenancies and being labeled “intentionally homeless”. March 2015 Ensure the ECC Private sector landlord accreditation scheme Gwyn OwenHousing BudgetEnsure quality of tenanciesReview July 2014 Ensure a fit for purpose commissioned floating support service Simon Harniess Housing Budgetdirect support for vulnerable adults with housing needs, eg debt liaison, discussion with landlords etc. Review July 2014 Review the commissioned Triangle Tenancy Sustainment scheme - whereby vulnerable tenants have their rent paid by ECC and where ECC liaises with landlords. This scheme could be rolled out to include other more vulnerable groups Simon Harniess Housing BudgetTo ensure sustainable tenancy for those with substance misuse issues and who are offenders and other vulnerable groups Review Extension June 2014 Implement changes April 2015 Engage with Housing partners to ensure the proportion of housing development that is expected to be delivered as ‘affordable’ housing. Review the ned for and provision of ‘extra care’ housing and agreed with stakeholders Simon Harniess Gary Heathcote Housing BudgetEnsure appropriate housing to meet population needs Commences July 2014 Financials in relation to these actions are addressed our Independent living Commissioning Strategy

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Percentage of Households living in Fuel Poverty The Baseline and the Story behind it Excess winter deaths are associated with poorly heated homes and this in turn is associated with fuel poverty. Fuel poverty and poorly heated homes are also associated with increased levels of poor mental health. Fuel Poverty historically occurs when 10% of income is needed to heat the home to accepted standards. It depends on income, fuel price and how easy the home is to keep warm. Particular cohort at risk are older people, including those who come into the social care system. Also those on benefits and low income families. Fuel poverty may be worse for people in private rented accommodation, and people who are single occupiers. Fuel costs continue to rise at a rate exceeding inflation Changes to the benefits system particularly aimed at working age adults may mean that some of these adults are drawn into fuel poverty. Also the increased threshold for single room rate means that more of the population group are affected and potentially subject to fuel poverty. The £500 per week benefits cap may impact on a small number of families in Essex. The condition of the housing stock in Essex is also relevant. There are a large number of owner occupiers in Essex but some of these may be asset rich but cash poor. The condition of private rented accommodation is also relevant because private rented accommodation quality is often poorer than social housing. Tariffs for those on payment meters are also higher than tariffs for those who can pay on direct monthly debit. Home insulation grants are now less available than they have been in the past, (for example, the Warm Front initiative expired a year ago). Conversely more people are in employment although average wages have not increased in line with inflation but the minimum wage has increased. There is variable information on home improvement information to reduce fuel poverty, so part of the role of Home Improvement Agencies (HIAs) is to help customers navigate this process Given all the above it is hard to understand why the data suggests a reduction in the numbers in fuel poverty.. 46

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The Curve we need to turn While data suggests a reduction in numbers in fuel poverty, it is unclear why this should be the case given the economic downturn and the increasing cost of fuel. We need to better understand the trend but continued improvement may be a challenge in the short term and we might expect a continuing rise in numbers. Improvements in the Essex economy will help address the numbers in fuel poverty so action under our commissioning strategy for economic growth is critical. Issues to address in order to turn the curve Responsibility for housing is primarily with district, city an d borough councils and ECC needs to work in close partnership. A number of initiatives led by the district and borough councils are underway linked to their role in environmental health and housing. These tend to take an education raising role, making residents and landlords aware of the problems and solutions available to them. One example is the work underway at Chelmsford City Council, who in December 2013 organised an information seminar to discuss the impact of cold and damp homes. This is likely to be an area of increasing focus for district and borough councils as the legislation around housing quality tightens. From 2016 private residential landlords will be unable to refuse a tenants reasonable request for consent to energy efficiency programmes; whilst from 2018 it will be illegal to rent out a residential or business premise that does not reach a minimum energy efficiency standard to be set at Energy Performance Certificate (EPC) rating E. Currently nearly 9000 (14%) of Chelmsford homes are in bands F or G, and will not be legal to rent out when the legislation comes into force. ECC are working with districts and boroughs to implement the Green Deal within Essex through the Essex Energy Partnership.. We also need to work closely with private sector landlords as well as housing providers. We have little control over fuel costs, we can address economic growth and support employment in some to get people out of fuel poverty and we can ensure access to benefits where appropriate ( this will alleviate the effects but not address the fuel poverty per se). We also need to support improvements in housing stock. We need to recognise that initiatives in the short term will need to focus on vulnerable groups to mitigate the impacts of fuel poverty rather than reduce fuel poverty per se. ECC's sphere of influence to address fuel poverty is more with private rented accommodation and owner occupiers, and these should be priority groups for interventions, as they are relatively less well regulated. The key role of housing means we need to work with districts, city and boroughs in this area. We need to ensure help reaches the most vulnerable clients. This will involve floating support We need to ensure all services in contact with the population identify households at risk of fuel poverty, can offer simple advice and support or can appropriately refer. This may include proactive action in times of risk. Continue to work with CVS to implement schemes to alleviate fuel poverty in those hardest hit. 47

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48 Percentage of Households living in Fuel Poverty ActionLeadResourceIssues addressed Timetable Economic improvementSee economic growth commissioning strategy Increasing income of households will reduce fuel poverty See economic growth commissioning strategy Joint work with DC,BC and CitySimon HarniessNil requiredCoordinated response across agencies From Sept 2014 Work with district and borough councils linked to their role in environmental health and housing linked to Outcome on sustainable environment including ensuring education and information to people on saving fuel costs. Chris FrenchSee sustainable environment commissioning strategy and PH grant Improved education on how to keep warm and reduce fuel costs From Sept 2014 Work linked to Outcome for sustainable environment around reducing household fuel costs. ECC are working with districts and boroughs to implement the Green Deal within Essex through the Essex Energy Partnership See sustainable environment commissioning strategy reduce fuel costsThe first Essex County Council Community Energy Switching scheme was launched in January 2014 with over 3900 residents registering

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49 Percentage of Households living in Fuel Poverty ActionLeadResourceIssues addressed Timetable commissioning home improvement agencies Sheila Norris, Simon Harniess, Jane Richards Through existing Grant process Rapid adaptions to reduce fuel costs From Sept 2014 Use of whole workforce to identify and signpost those at risk due to fuel poverty. Simon Harniess /Chris French Nil required.Identify those at risk and enable advice and support to be directed as required From September 2014 Ensuring access to benefits including grants for improving housing stock Simon HarniessExternal sourcesImproved insulation and cheaper fuel needs Ongoing Commissioning floating support servicesSimon Harniess, Housing Related Support Improve support for vulnerable groups From Sept 2014 Focused initiatives via CVS targeting those most vulnerable Chris FrenchPH grant resourced within current MTRS Target support for those at risk of poor health outcomes through fuel poverty Winter 2014 Also the current actions within the Sustainable Environment commissioning strategy’ Peter KelsbieAs per our sustainable environment commissioning strategy’ Improved education, reduced fuel costs to heat homes. As per sustainable environment commissioning strategy

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Prevalence of mental health disorders among children and adults Children The Baseline and the Story behind it National research highlights that good emotional and mental health is fundamental to the quality of life and productivity of individuals and families. Poor emotional wellbeing and mental health can lead to negative outcomes for children including educational failure, family disruption, poverty, disability and offending. These can lead to poor outcomes in adulthood such as low earnings, lower employment levels and relationship problems which can in turn affect the next generation. Research has also shown that half of lifetime mental illness arises by the age of fourteen; that the most crucial influence on a child’s emotional wellbeing and mental health is parenting influence within the first year’s of a child’s life and that early attachment and bonding between parents/carers and their babies is vital for a child’s development. Essex surveys of schoolchildren show that pupils with poor emotional wellbeing are twice as likely to say they are afraid to go to school because of bullying and that they have been a victim of crime; they are significantly less likely to enjoy school and more likely to want and need more help from teachers. CAMHS services are complex and fragmented and commissioning is not joined up. The CAMHS Tier 2 service for those with emerging mental health issues Is commissioned and delivered by ECC; the 7 CCGs commission NEPFT to deliver Tier 3 for those with mental health issues in North Essex and SEPT to deliver Tier 3 in South Essex. There is a continuing focus on early intervention based on national evidence that this saves costs upstream with support for school and community based provision. The 2013 JSNA for Children’s Emotional Wellbeing and Mental Health found that fewer than the expected number of children needing a service at both Tier 2 and Tier 3 level were receiving support. It concluded that there is a complex, fragmented and poorly understood set of services in place across Essex with a high degree of concern among professionals about access to CAMH Services. There is differing access criteria and service delivery across Essex with a lack of clarity on pathways between services. Estimated need and demand levels are generally static (Child and Maternal Public Health Observatory CHiMAT estimate 7% children have a Tier 2 level mental health need and 1.85% children have a Tier 3 level need); however the complexity of referrals is increasing while resources are not. We are therefore seeking efficiencies through evidence based commissioning, reduced management costs, improved joint working with other services and increased support provided from universal services. National benchmarking data shows that across Essex health invest less than the average health investment in CAMHS across England..

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Prevalence of mental health disorders among children and adults Children The Curve we need to turn We currently have no data t around the actual number of young people in Essex who have mental health issues. We only have likely numbers based on extrapolation from national surveys that do not provide a basis for a measurable trajectory. The 2013 JSNA for Children’s Emotional Wellbeing and Mental Health shows that some 14.5% Tier 2 need and 75% of Tier 3 need is met through direct intervention- though the Tier 3 level is very variable across the County. Experience and feedback from providers shows that the complexity of cases is increasing. Issues to address in order to turn the curve Ensure the best start through strong parenting support and pre school education as outlined in best start in life Outcome Work with schools to improve resilience and reduce harm through stresses such as bullying Integrate commissioning across ECC and the CCGs Develop and implement a redesigned Service Model which simplifies access to and provision of interventions Improve performance management of provision Improved joint working with other services and an integrated holistic approach to ensure improved wellbeing Easier access to CAMHS support for children and professionals with a quicker response to needs. More children have appropriate evidence based support that results in improved emotional wellbeing and mental health. Prioritisation for Children Looked After and care leavers with support for emotional wellbeing at all stages of their care journey..

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52 Strategic Actions ~ Prevalence of mental health disorders among children ActionLeadResourceIssues addressedTimetable Optimise early years support around parenting and preschool education as per best start in life commissioning strategy Chris Martin, Barbara Herts ECC and health budgets Strong secure attachment and emotional development As per best start in life commissioning strategy Re-commissioning and integration of services jointly across Southend, Essex and Thurrock and the 7 CCGs. Barbara HertsCAMHS commissioning budget (ECC and health) ECC contribution resourced within MTRS Develop best model for services and address the gaps highlighted by the external JSNA, such as therapies for behaviour, ASD and Autism, Self- harming and support for looked after children on the edge of care Nov 2015 Work with Healthy SchoolsTim Coulson, Chris French Healthy Schools Budget, PH grant - resourced within the current MTRS address issues such as bullying and help develop resilience in young people. Ongoing, develop 2015

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53 Strategic Actions ~ Prevalence of mental health disorders among children ActionLeadResourceIssues addressedTimetable Improve transition to adult mental health services. Barbara HertsCAMHS and Adult MH budgets - resourced within the current MTRS Improve experience for service users Commission specific support for those at high risk including children who are looked after and those leaving care Ian WakePH grant - resourced within the current MTRS Mental health needs of care leavers April 2015

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Prevalence of mental health disorders among children and adults Adults The Baseline and the Story behind it Mental Health issues are the key cause of ill health in the population. Amongst older people over a third are likely to suffer from depression People with mental health issues live 10 to 20 years shorter lives than those without ( depending on condition) 75% of mental illness other than dementia starts by a persons mid 20’s There is a strong link with deprivation and socio economic factors. Debt and workplace stress are causes of poor mental health Mental health issues are strongly associated with employment. Loss of work leads to increased mental health issues and those with mental health issues often find it hard to secure or maintain existing employment. The current economic climate has impacted on need. Amongst older people, social isolation is a key cause of mental health issues Carers are at particular risk of mental health issues Dementia is an increasingly important and common issue within the population with numbers expected to rise rapidly in coming decades Number of total contacts with mental health services, rate per 1,000 population - latest figure 256. In-year bed days for mental health, rate per 1,000 population - latest figure 221 Directly standardised rate for hospital admissions for mental health - latest figure 197 There are two key specialist mental health providers, SEPT and NEPFT. There is a joint S Essex commissioning strategy including the Unitaries which is changing the shape of future services. In N Essex, the strategy is at sign off stage, due to be implemented later in Change drivers include the need to move toward an outcome and recovery based services, and financial constraints. The later has led to a marked reduction in 3rd sector, often preventative service,funding. Similarly health partners funding has reduced. The Curve we need to Turn Adult Mental Health While we have some service utilisation data we have no sense of the local prevalence of mental health issues in adults although we are aware of the scale of the problem through extrapolation from national surveys and studies. It is therefore not possible currently to establish a baseline or a measurable trajectory. (see key issues to address in slides)

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Issues to address in order to turn the curve (see key issues to address in slides) Early years initiatives are key in protecting mental health in adults and are described elsewhere Seamless and sound Transition from children to adults services is essential. There are particular issues around access and quality of CAMHS services There is a need to address the broader determinates that drive metal health prevalence. These include addressing poverty, debt and unemployment as key drivers of poor mental health. Economic growth commissioning strategy activity will help in this area. There is a specific issue around low employment for people with mental health issues who suffer harm from the ensuing hardship more than their mental health issue. People with mental health issues need focused support around access to benefits and housing. These issues link to our economic growth outcome (housing) People with mental health issues are at high risk related to poor lifestyles and need focused support around smoking, alcohol, diet and exercise. Up to 30% of older people are depressed but only 1 in 6 has raised this with their GP and of those who have only half are being treated. There is a need to, with health colleagues, identify people especially older people with depression and to manage the condition. We need to consider opportunities around ACL (Adult Community Learning ) and libraries in supporting particularly older people and helping address mental health needs We can provide resources to enable people to develop resilience within their community including through libraries and workplaces. We need to optimise our communities potential to reduce social isolation and provide support - linked to our independent living Outcome Informal carers are crucial to supporting our population and are often under considerable mental stress. We particularly need to consider their needs. As dementia becomes more common, we need a clear joined up approach with health colleagues to its management We need to ensure intensive enablement packages for those who are most in need and have the most re-enablement potential. The development of personal budgets and personal health budgets, means that individual packages of care can be commissioned to meet individual outcomes and deliver efficiencies. People need to be enabled to live as independently as possible with appropriate support. The principle underlying commissioning should be a recovery focus. Key will be ensuring appropriate housing so people can move from hospital and residential care through intensive reablement to supported living options that maximise their independence Efficiencies and quality gains will be delivered by the accommodation strategy. We will do this by e.g. supporting people back into employment, reduction in medication, getting people out of hospital.. Care and Support (£1.5m) savings are dependent on an appropriate provider being found for a new Intensive Enabling housing contract We are working to achieve the outcomes in the MH framework. From a policy perspective the key driver is “No Health Without MH “

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56 Strategic Actions ~ Prevalence of mental health disorders among adults ActionLeadResourceIssues addressedTimetable Early years initiatives are key in protecting mental health in adults and are described elsewhere Seamless and sound Transition from children to adults services is essential. There are particular issues around access and quality of CAMHS services Address the broader determinates that drive mental health prevalence including economic growth as detailed in our economic growth commissioning strategy with specific additional focus on employment for people with mental health issues. Helen Taylor /Ros Dunn See commissioning strategies for economic growth and independent living Financial hardship and unemployment are key causes ill health and early death in people with mental health issues April 2015 Ensure those with mental health issues are supported around access to benefits and housing as well as focused lifestyle advice around smoking, alcohol, diet and exercise as described in our economic growth commissioning strategy (housing) and this commissioning strategy (health and wellbeing) Helen Taylor, Ian Wake, MH budget, PH grant - resourced within the current MTRS As above, access to housing and support around lifestyles especially smoking is important Sept 2014 There is a need to, with health colleagues, identify people especially older people with depression and to manage the condition. Ian Wake PH grant - resourced within the current MTRS Reduce burden of depression in older people and people with long term conditions Sept 2014 Optimise the potential of communities in line with “Who Will Care” to reduce social isolation and provide support linked to our independent living commissioning strategy Sheila Norris As per our independent living commissioning strategy Reduce social isolation Consider and address the needs of carers as per our independent living commissioning strategy Sheila NorrisAs per our independent living commissioning strategy Carers are a high risk group for mental health issues

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57 Prevalence of mental health disorders among adults ActionLeadResourceIssues addressedTimetable Commission with partners a joined up approach to managing dementia Helen Taylor As per our independent living commissioni ng strategy Better support and management for people with dementia, their families and carers Sept 2014 Mental Health Demand Management will be delivered through the Accommodation Pathway and Accommodation Strategy and care package reviews & housing brokers. Helen Taylor, MH Budget as detailed in our independent living commissioni ng strategy Appropriate accommodation for people with mental health issues – financial benefits of the Accommodation Strategy are described in our independent living commissioning strategy Oct 2014 Commission intensive enablement packages for those who are most in need and have the most re- enablement potential. Helen Taylor MH budget as detailed in our independent living commissioni ng strategy Ensure optimal independence linked to our independent living commissioning strategy – financial benefits of Intensive Enablement are described in our independent living commissioning strategy Jan 2015 Partnership agreements are in place to ensure integrated commissioning. In S Essex there is a virtual team of commissioners working to implement the agreed strategy. We are considering whether this team will become a joint team with a pooled budget, or will continue as a virtual team with a written agreement in place defining how the team will work. Helen Taylor, Nil required.Better services through a coordinated approach to commissioning

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60 Teenage Pregnancy Rates The Baseline and the Story behind it Under 18 conception rates have been steadily declining. Rates in Essex are 23.9 per 1000 which is marginally higher than the East of England rate, but lower than the England rate of There are differences across Essex with the highest rates in Harlow, Tendring and Basildon. This indicator has been long standing with information being captured from 1999 to present. Previously it had a high profile but latterly it has reduced in priority. This culminated in the loss of the ECC Teenage Pregnancy Coordinator post and a reduction in the resources allocated to this outcome (previously it had been heavily resourced). Whilst conception rates are steadily declining in Essex abortion rates have been increasing. There is a strong association between teenage conception rates, low educational attainment, low aspirations and poor employment prospects. In addition there is evidence in some areas of a culture of acceptance around teenage pregnancy. The Public Health Outcomes Framework sets the national policy context for the drivers for change and teenage pregnancy was also mentioned as one of the four key priorities in the government’s 'A framework for sexual health improvement' which was published in March ECC's Sexual Health Needs Assessment (SHNA) provides detailed information on commissioning requirements which will influence the baseline. Other drivers for change may include Healthwatch who are interested in this area. It is anticipated that the future trend will see the decline continuing, but this will need to be closely monitored. A reduction in the role of the Youth Service and pressure on SRE in schools and particularly the ability to influence academies going forward may have a bearing on the future trends. Current provision and gap analysis (where commissioning intentions are outlined) is provided in the Public Health Commissioning Intentions Plan (this is embedded in the section on current actions). The SHNA is also available which discusses the issues. The Curve we need to turn Teenage pregnancy rates are declining in Essex therefore the curve is currently moving in the right direction. However the rate of reduction nationally increased from 2007 but Essex has seen no such acceleration. Renewed vigour is required locally to turn this curve. Issues to address in order to turn the curve It is important to ensure this is back on the agenda in schools and the Youth Service. We need to work with schools, linking this issue into the wider 'Risky behaviour' work and wider SRE provision as well as lifting aspirations in young people. We must commission to ensure access to services at appropriate times and locations for young people. Work needs to be focused on changing young people's attitudes to teenage pregnancy.

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61 Teenage Pregnancy Rates ActionLeadResourceIssues addressed Timetable The Public Health Commissioning Intentions Plan and SHNA demonstrate current and future actions. Jane Richards PH Grant - resourced within the current MTRS Accessible service offering evidence based care Sept 2014 onwards Commission appropriate, accessible sexual health services that meet the needs of young people as detailed in the above Strategy. Jane Richards PH Grant - resourced within the current MTRS Work with schools and the Youth Service to ensure teenage pregnancy risks are addressed Jane Richards/T im Coulson PH Grant - resourced within the current MTRS Better education and improved resilience reducing risk Sept 2014 Work with schools, linking this issue into the wider 'Risky behaviour' work and wider SRE provision as well as lifting aspirations in young people. Jane Richards PH Grant - resourced within the current MTRS Ongoing role out Ongoing education opportunities for teenage mothers linked to our education and lifelong learning commissioning strategy, Jane Richards/T im Coulson PH Grant - resourced within the current MTRS Enable best life chances and achieved potential in this group April 2015

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62 Teenage Pregnancy Rates ActionLeadResourceIssues addressed Timetable All sexual health service specifications to include KPIs focusing on increasing access to contraception and other related sexual services targeting young women aged under 18 Jane Richards PH Grant - resourced within the current MTRS Appropriate accessible services From Sept 2014 Service specifications for the 5-19 Healthy Child Programme (HCP) include KPIs requiring providers to demonstrate action taken to contribute to reducing teenage pregnancy rates through provision of appropriate health promotion and education interventions and signposting to specialist services where required. Jane Richards PH Grant - resourced within the current MTRS Better education and improved resilience reducing risk From Sept 2014 Roll out of Risk Avert programme to increased number of Essex schools Jane Richards PH Grant - resourced within the current MTRS Ongoing Joined up approach between commissioned services and Essex Youth Service to improve access to health improvement and education Jane Richards PH Grant - resourced within the current MTRS April 2015 Active engagement of voluntary and community sector organizations who are well placed to deliver interventions with young people Jane Richards PH Grant - resourced within the current MTRS Allow access to hard to reach groups April 2015

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Views, opinions and preferences of: the general population; As part of the “Who Will Care?” commission, a group of residents were asked to look at priorities for spend of health and social care resources in terms of the current spend and the proportion of the budget that should be spent in that area. Public health was second only to pharmacies as the area where more spend was needed. This public view reflects the drive in both health and social care commissioners to increase the focus on prevention of ill health. Public health principles in Essex were developed by a members reference group drawn from across the council. The group felt the principles should include:- A local approach, address inequalities, recognition of the broad determinates of health and should involve evidence based solutions. specific population groups; Housing and Homeless ness - We have undertaken a survey of people who are street homeless that informed our needs assessment and provides valuable information on gaps in services and required service provision. Substance Misuse – we will continue to operate the successful Carers, Users and Families (CUFs) Network across the county to ensure the operation of the current “You Said; We Did” process of engagement with this historically hard to reach care group. In addition we will continue to explore opportunities to involve clients and families with the commercial activity involved when procuring new service provision and managing and monitoring the continuous improvement agenda through the regular Performance Monitoring Review (PMR) process. Mental Health in Children – Consultations with service users and their families have highlighted the need for improved awareness of services and of mental health issues and for easier access to services that they can trust and that make them feel comfortable. Users are being involved in the redesign process. For Adults with mental health issues we are currently getting service user engagement through MH trusts following loss of funding to existing arrangements. Access to advocates generally are commissioned jointly across social care, not just MH contracts. Service user / customer views

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64 Our Partners and our Relationship with them Name of key partner or partnership How they will contribute to achieving the outcome/addressing the issues How we will work with them (including who the lead contact is if known) NHS including CCGs, NHS England We will need to work with NHS Commissioners to ensure a shared agenda and a joined up response to commissioning in a number of the areas where action is needed to deliver the Outcome. Leads will be the Heads of Health Improvement, the CPH and the ICDs alongside the DPH. CPH are part of the CCG executive groups and work will be through these bodies as well as the Health and Wellbeing Board and its Business Management Group. Primary care, community, mental health and acute providers. We will develop strong contractual relations underlined by mutual respect and understanding as well as a common purpose to ensure optimal delivery of commissioned services. as well as a joined up approach to addressing lifestyle risks. They may also have a role in identifying at risk groups eg Community Health Providers have frontline staff such as a district nurses who are able to identify households in circumstances of fuel poverty. Leads will be the ICDs, Heads of Commissioning: Public Health and Wellbeing and Tier 4 colleagues. Meetings will be with providers and will be both informal and formal contract meetings. Districts, Boroughs and City Meeting many of the health outcomes will require extensive District/Borough Council involvement particularly, but not limited to, physical activity housing, planning, licensing, and the economy. District and Borough Councils are partners in general economic growth activity and national government in the development of national initiatives, as well as lobbying for inward investment. The districts, city and borough councils have statutory responsibility for housing stock and have a key role around fuel poverty, quality of housing and homelessness. There are variable links with DC/BCs. Currently public health links have waned and will need to be redeveloped. There are links around housing with Tier 4 lead involved and leads around Economic growth

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65 Name of key partner or partnership How they will contribute to achieving the outcome/addressing the issues How we will work with them (including who the lead contact is if known) Police and Crime Commissioner, Police, Probation (including any future Community Rehabilitation Company) and Prison. Community safety partnerships. Addressing mental health, alcohol, substance misuse, domestic abuse and the needs of offenders and ex offenders will require close links with these bodies. Community safety partnerships, as district specific groups which come together to review broadly defined community safety could address housing safety Lead: Head of Commissioning: Public Health and Wellbeing. This work will be managed through a number of meetings and fora including the Reducing Re- offending Commissioning Group, the Integrated Substance Misuse Commissioning Group, Prison Healthcare Partnership meeting (with NHS England), Domestic Abuse Board and Commissioning Group. Links will be developed with Community Safety Leads across the County. Voluntary sector Delivering bespoke targeted services to vulnerable groups who engage poorly with statutory services will mean we need to develop the voluntary sector as a key group of providers. Links with the Voluntary sector are needed to encourage development of provision aimed at skills development, work readiness etc. targeted to specific groups. Wrt Housing Children's charities, such as Barnardo's may be able to identify those at risk of homelessness.. ICD Lead,Place heads of around Economy, Lead Heads of Health Improvement working with ICD lead and Tier 4 People Commissioning colleagues

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66 Name of key partner or partnership How they will contribute to achieving the outcome/addressing these issues How we will work with them (including who the lead contact is if known) Essex Citizens The people of Essex will need to be supported to be able to make the right life style choices through empowerment and through information. We will need to develop a range of methods to ensure strong engagement. Delivering Who Will Care demands a different and growing role for Essex communities, ICD lead, Leads tier 4 Commissioners including Heads of Health Improvement. User fora Where we commission specific services, we need to ensure they meet the needs of the target groups. This is especially important in areas where users are reluctant to engage with services eg people who misuse substances Leads Tier 4 Heads of Commissioning including Heads of Health Improvement. Partners in Education We have very good partnership links with schools. Other partners include Her Majesty's Inspectorate (HMI) and Ofsted and again relations are good with ECC. There are productive working relationships between ECC and headteachers associations for primary secondary and special schools. To deliver Employment we need to work with Education and Training Providers to encourage development of provision, and in partnership with employers to ensure provision is aligned to need We need to look at the contribution of ACL and libraries to improving lifestyle choices Tier 3 education lead and tier 4 heads of, Place economy lead and public health heads of health improvement. Heads of Leads for ACL and early years Job Centre Plus We need to work with Job Centre Plus to ensure provision is appropriately targeted to need, that unemployed workers are appropriately channeled towards vacancies, and to ensure employed workers are provided with relevant skills development opportunities. Job Centres are increasingly a site for health checks and lifestyle advice. Place lead for Economy, ACL lead commissioner, Health Improvement Head

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67 Name of key partner or partnership How they will contribute to achieving the outcome/addressing these issues How we will work with them (including who the lead contact is if known) South East Local Enterprise Partnership (and other relevant regional partnerships) Partnership is required to foster economic growthEconomy lead, Place Commissioning Employers This will encourage job growth and development, identify skills shortages and encourage partnerships with education and training providers to ensure these are addressed. We need to work with employers around workplace opportunities for people with mental health issues and those with learning difficulties. We need to explore the workplace and workplace health champions in improving health through health checks and lifestyle choices. The role of major public sector employers such as LA and NHS is key Economy lead, Place Commissioning, MH and WAA commissioning lead and head of health improvement. Housing Providers Partners in addressing homelessness and poor housing include all types of housing providers, as well as internal ECC partners (such as children’s operational teams who are important routes by which families at risk can be identified). Registered housing providers//housing associations and private sector landlords are key partners in addressing fuel poverty. Housing Lead Tier 4 Essex County Council Environment Team and Essex Energy Partnership Help in addressing fuel poverty. Through sustainable environment outcome leads

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69 Public Health Category Strategy – Current Contractual Arrangements Context Business Transfer Agreements & Impact on Commissioning Intentions Some of the long term contracts with suppliers were created when the provider arms were split from the primary care trusts. Some of these contain business transfer agreements that limit the value of services that can be reduced, terminated or subjected to competition. Provide (CECS) Contract Commenced 01/04/2011; Duration 5 years so expires 31/03/2016 Allows for 5% of services to be contested in year 1 with and additional 2.5% cumulative each year Not more than one major service can be contested in any one year. Ability for flexibility where “any willing provider” model is used. 12 months written notice to terminate a service ACE Contract commenced 01/04/2011 ; Duration 5 years so expires 31/03/2016 Allows for a value of services to be contested each year on a cumulative basis based on the total PCT business. Using baseline this could be interpreted as % as follows : 11/12 = 4.8% ;12/13 = 30% ; 13/14 = 55% ; 14/15 = 80% 15/16 = 100% 12 Months written notice required to terminate service. New Contracts 1 year contract period or 6 months notice (includes Acutes, SEPT and NELFT) New contracts for DAAT services let in 2012 – already on ECC terms. Other Contracts All other contracts have 6 months notice. Supplier Break down of Services under Master contracts in map on previous page Anglian Community Enterprise CICNHS Health Checks Programme Health Improvement & Wellbeing Nutrition, Obesity & Physical activity Tobacco Control & Smoking Cessation Children 5-19 School Health Service Health Trainers Breastfeeding Support Sexual Health Services Central Essex Community Services CICSexual Health Services Health Trainers Breastfeeding Support Children 5-19 School Health Service Tobacco Control & Smoking Cessation Health Improvement & Wellbeing NELFT Falls Prevention 5-19 Healthy Child Programme (School Nursing/Healthy Schools) Sexual Health Services (including GUM) Adults & Children's Weight Management Programmes NHS Health Checks SEPT 5-19 Healthy Child Programme (School Nursing) Sexual Health Services Children's Weight Management programme GP’s LARC/IUCD Insertion (Sexual Health Services) Health Checks Shared Care Opiate Misuse PharmaciesChlamydia Screening/EHC Supervised Consumption Needle Syringe Provision Health Checks

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70 Public Health Category Strategy – Sub-Categories covering provision of Public Health Sexual Health All sexual health services including Family Planning, Testing and treatment of Sexually transmitted diseases, and advice prevention and promotion Nutrition obesity and physical activity Weight management interventions and prevention and promotion Physical activity interventions, community based recreational activities, school based activities and prevention and health promotion. Tobacco Control and Smoking Cessation Stop Smoking services and interventions, smoking uptake prevention, smoke free places, enforcement and regulation of tobacco supply, prevention and health promotion and promotional activities. Drugs and Alcohol services Substance misuse, Drugs and alcohol misuse services Breastfeeding support Support and advice for mothers and parents, education, training for healthcare professionals Children 5-19 Health Programmes School health promotion and improvement, school nursing, health child programme, promotion and prevention activities. Health Improvement and wellbeing Health Improvement and Wellbeing preventative measures. Health Trainers Health trainers, community safety and other general prevention Health Checks Aims to help prevent heart disease, stroke, diabetes, kidney disease and certain types of dementia. Everyone between the ages of 40 and 74, who has not already been diagnosed with one of these conditions or have certain risk factors, will be invited (once every five years) to have a check to assess their risk and will be given support and advice to help them reduce or manage that risk. Sexual Health Treatment of HIV Services provided by Clinical Commissioning Groups and Public Health England In Scope Out of Scope Scope Public Health Category Strategy The current Public Health Category Strategy is outdated and will be refreshed in line with this commissioning strategy. The data within this strategy forms the basis for identification of the business requirements within the Category Strategy. Comprehensive spend and market analysis the next step now that full 13/14 spend data is available in May 14. The output of the Category Strategy will be detailed short, medium and long term commercial plans to deliver the Public Health commissioning intentions and ensuring best value. Part of this work will include consideration of the outcomes covered in this strategy that are not directly delivered as services by the Public Health grant and how these could be contributed towards through building Social Value throughout the Strategy and any resulting sourcing processes. The market is not mature in this area and will require support and encouragement through small steps and changes to develop their capacity to deliver added value – and or their ability to communicate what they already do in a way which scores highly during a tender process. Some of this is about how we construct our specifications and selection and award criteria. Commercial Market Development can also support in pre-tender market engagement, particularly with the Voluntary Sector to instigate these discussions.

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Social Value Act Requirements within Public Health Category Strategy Social value has been defined as “the additional benefit to the community from a commissioning/procurement process over and above the direct purchasing of goods, services and outcomes” There is no authoritative list of what these benefits may be Social value is best approached by considering what is what beneficial in the context of local needs or the particular strategic objectives of a public body. An example of procuring deliberately for additional Social Value within the guidance - A health contract which, based on consultation with service users, includes criteria such as investing in employees, the ability to evidence training, improved motivation and outcomes, and also the ability to meet the desires of the community. – All of which ECC can demonstrate through it’s own recent contracts. The specific requirements upon us in delivering the Public Health Strategy – Public bodies must consider how the services they commission and procure might improve the economic, social and environmental wellbeing of the area. The Public Services (Social Value) Act does not take a prescriptive approach to social value. It simply says that a procuring authority must consider: How what is proposed to be procured might improve the economic, social and environmental well-being of the relevant area. How, in conducting the process of procurement, it might act with a view to securing that improvement. The benefits? Seeks to create maximum benefit for the community and drive up service quality Lead to cross-departmental savings; and Support community organisations to enter the market Supports Social Economy Widens the pool of suppliers in many areas of public services Supports commissioners to combine their economic, social and environmental objectives and embed them across all the strategic procurement functions instead of approaching them in silos. (through Category Management) Aligns Social Value with local needs Local economic growth & wellbeing Commercial will support Public Health to deliver added Social Value through comprehensive Corporate Impact Assessments at both a strategy & individual project level, support and guidance in specification writing and development of appropriate selection and award criteria and also through earlier engagement with the Provider market to raise awareness and stimulate innovation so that offers made through tendered submissions can be incorporated into contracts and measured through Supplier Performance, thus creating a golden thread from intention through to implementation.

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Delivering change within our financial envelope (1/2) Summary The Essex Public Health grant is already over 5% below target. Additionally, we have already made corporate savings and have needed to return resources to partners (e.g. CCGS). The workings below show that if we can attract our “fair share” capitation we might be able to deliver this strategy. We could not manage this with a further 20% reduction that would leave us 40% below capitation. 2014/15 Financial Position In 2014/15 Public Health budget aligned to this outcome is wholly funded by grants and other income. The gross expenditure budget for Public Health services is £51.7m. The breakdown of this budget is shown in the adjacent table. MTRS position All planned expenditure on Public Health initiatives will be fully funded from within the allocated grants. An element of the grant has and will continue to be used to fund invest to save schemes aimed at reducing the demand for residential care. The financial benefits from these initiatives will accrue in our People in Essex can live independently. Commissioning strategy. Budget area2014/15 Original Budget (£m) Public Health - Expenditure£51.7m - Income-£2.7m - Grant Income-£49.3m Net Total-£0.3m The following are included in the latest MTRS position £1.5m of overheads will be funded from Public Health grant on a permanent basis £2m of procurement related savings related to Public Health contracts have been planned (£1.3m in 2014/15 and an additional £700,000 in 2015/16) £841,000 in 2014/15 increasing to £1.1m in 2015/16 will be transferred to CCGs to align funding with commissioning responsibilities. From 2015/16 there is a risk that the Public Health grant allocation will be reduced by a £1.1m as a result of formula adjustments and the reallocation of resources across partners. The above represent a 11% reduction of the funding originally available by 2015/16. It should be noted that to fully claim the Public Health grant we must be able to demonstrate that the monies have been used in accordance with the grant criteria, therefore we must be able to identify appropriate expenditure that is currently funded from ECC base budget to effectively support any corporate budget reduction. Delivery of many indicators in this outcome largely depend on commissioning activity elsewhere especially around: early years, schools, economy, safer Essex and with housing partners. The financial delivery of these aspects will be discussed under the relevant Outcome Strategy.

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10% reduction in Resource It should be possible to deliver the Outcome strategy as laid out within this document with a 10% reduction in resources dependent on: Driving savings from service reconfiguration and the provider market (anticipated up to £3.2m) Exceed existing the £2m savings target in the current MTRS by 1.2m. 74 Scenario2015/16 funding available £m Reduction £m Revised 2015/16 funding available £m 10% reduction % reduction Impact of reduced resources on Strategy delivery The strategy is based on an assumption that the funding available will be in line with the MTRS although we know the reality is that in 2015/16 and subsequent years there is a gap between current budget requirement and the available funding that will need to be addressed. Delivering change within our financial envelope (2/2) Baseline The strategy detailed can be delivered within the existing MTRS envelope through sound procurement and investment decisions. This will include “invest to save” schemes which will release savings to ECC, in particular Adult Operations and potentially to CCGs although these benefits have not been fully calculated. 20% reduction in Resource The key factor here governing success will be political and officer pressure to secure Public Health funding for Essex which aligns with the targeted spend per head of population on Public Health Services Even without the resource loss to CCGs and Thurrock detailed above we are 5% below target. Securing a settlement on this basis would potentially enable delivery of the Strategy and allow a 20% reduction in baseline. ACTION IN THIS AREA MUST BE A PRIORITY Without this resource delivery of a 20% reduction would be very challenging given the statutory requirement for services in sexual health, substance misuse and school nursing. These areas have been subject to severe funding cuts and efficiencies have been driven out where possible. The remaining resource is focussed on lifestyle improvement and addressing inequalities - it would likely be this area that would have to look at with a view to considering alternative approaches to service delivery or decommissioning. This would result in a negative impact in the short term on delivering lifestyle gains and in the longer term on life expectancy and be challenging politically.

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Information Governance and Information Technology Strategies. 75 This commissioning strategy will be supported by Information Services, and the approach applied will be consistent across all Outcome Strategies. All initiatives resulting from the Outcome Strategies will be analysed and reviewed to ensure that the appropriate information and technology needs are identified and clearly defined; and to ensure that they are in line with, or influence, the Information Governance and Information Technology Strategies. As part of this analysis, key programmes underway will be mapped and utilised as appropriate to avoid duplication of solutions, reuse our technology architecture where possible and optimise economies of scale for technology investment. Additionally, part of the Information Services Strategy function will horizon scan, identifying technology opportunities which may benefit the future operations of the organisation or those of alternative delivery vehicles and partners. Where technologies are identified as having capabilities to underpin or deliver the outcomes then Information Services will take appropriate action to ensure the best fit strategic solution is delivered for Essex. Where new projects are required to meet the needs of any initiatives, these will be set up by Information Services, following standardised internal processes and link into the other key programmes as appropriate. Key programmes currently underway include: Information Services Delivery Programme (ISDP) Transforming Corporate Systems (TCS) Customer Programme Next Generation Access and Broadband UK (NGA and BDUK) Social Care Case Management (SCCM) Future for Essex Support Services (FESS) With regard to this Outcome Strategy, other work underway for data sharing and technical integration with our partner organisations will be considered and reused as appropriate. IT will engage with the Commissioning Groups to analyse requirements and to recommend useful solutions. For example the use of App technology and Assistive Technologies.